Disability Insurance: What If an Employee Falls Ill?

Is a Sick Employee Automatically Eligible for Disability Insurance?

The short answer is no. For a disability claim to be approved, the employee’s medical condition must meet the definition of disability set out in the insurance contract. Although this definition may vary from one insurer to another, it is generally based on the following criteria: “A state of incapacity resulting from an illness or accident that prevents the insured worker from performing all the duties of their occupation and which requires ongoing medical care.”

After a period specified in the insurance policy, typically 24 months, the definition of disability is broadened to include “any gainful employment for which the employee’s education, training and experience would reasonably qualify them”. At that point, the insurer reassesses the case on this new basis.

Submitting a Disability Claim

To assess a claim, the insurer relies primarily on information provided by :

• the member, through the Insured Person’s Statement
• the medical team, through the Attending Physician’s Statement
• the policyholder of the group insurance plan, through the Plan Administrator Statement

While the employer may support the employee throughout the process, it is ultimately the worker’s responsibility to ensure that all required forms are submitted to the insurer. The review of a claim generally takes 5 to 10 business days after all documents are received. However, this timeframe can be extended by several weeks if information is missing or incomplete, which is why it is essential to complete all declarations carefully and thoroughly.

For a Prompt and Fair Process

The more accurately the submitted documents reflect the worker’s medical condition, the easier it is to understand the factors preventing them from performing their job or any other gainful occupation. The insurer’s decision is based solely on the information provided. A complete and well-documented claim therefore contributes to a fair and equitable assessment.

Do you have questions about managing disability insurance? Our team is here to help. Contact us.